Journal Article | Cardio-Metabolic

February 20, 2020



Dr. Ma. Haidee L. Ibañez, MD

Introduction:

Diabetes is a complex, chronic illness which requires continuous medical care and a multifaceted approach. Treatment strategies should not only be limited to glycemic control but patient self-management education and support as well. These are critical in the prevention of acute complications and reduction of long-term risk of complications.

 

Relevance:

The recommendations consist of screening tools, diagnostic tools, and treatment actions that are proven or believed to improve the quality of life of diabetic patients. For 25 years, ADA has made every effort to improve and update the Standards of Care to ensure that it would be the most authoritative of the current guidelines for diabetes care.

The Professional Practice Committee (PPC) of ADA is responsible for the review, revision, and update of the Standards of Care. They are composed of a multidisciplinary committee comprised of physicians, diabetic educators, dietitians, and others who have expertise in the range of areas concerned with diabetes.

 

Objective:

To improve and update the Standards of Care through a classification system that grades the quality of scientific evidence, which in turn would be used as the basis for ADA recommendations and a revised guideline. The classification system being used is shown in Table 1.

The recommendations stated in the Standards of Care do not aim to exclude clinical judgments but they must be applied in the context of clinical care with adjustments being made to tailor the needs of the patient.

 

 

Highlights:

 

General Changes:

The ADA has a new position statement from “Standards of Medical Care in Diabetes” to “Standards Care”. This update was made to address all aspects of care from medical issues to psychosocial issues including self-management, mental health, communication, complications, comorbidities, and life-stage considerations. The revisions made in the 2017 Standards of Care were made to clarify recommendations of the previous year and the minor changes were also based to reflect on the new evidence gathered.

 

Section Changes:

Section 1. Promoting Health and Reducing Disparities in Populations.

The section was renamed and is now centered on improving outcomes and reducing differences in populations with diabetes. It has been established that clinical practice guidelines improve the health of the entire population, however it was found out that diabetes care that is tailored for each patient have optimal outcomes.  Therefore, a combined system- level and patient-level approach should be made to improve population health. 

With an integrated approach in mind, the ADA highlights the importance of patient-centered care, defined as care that is respectful of and responsive to individual patient preferences, needs, and values, ensuring that patient values guide all clinical decisions. A few recommendations were added in this section that would help assess the social context of the patient as well as referral to local community resources and to provide self-management support.

Disparities such as access to health care, lack of health insurance, ethnicity, culture, differences in sex, community support, food insecurity, language barrier, financial constraints, and homelessness were suggested to be considered in tailoring treatments for each patient.

 

SECTION 2. Classification and Diagnosis of Diabetes

A new consensus on the staging of type 1 diabetes (Table 2.1) is updated in this section. Recent studies/ data have indicated that delivering a baby weighing 9 lbs. or more is no longer listed as an independent risk factor for the development of prediabetes and type 2 diabetes.

 

Previously, the recommendation to test women with GDM for persistent diabetes was changed from6–12 weeks’ postpartum to 4–12 weeks’postpartum. This recommendation was made to allow the test to be scheduled just before the standard 6-week postpartum obstetrical checkup so that the results can be discussed with the patient at that time of the visit.

 

A new table (table 2.7) describing the most common form of monogenic diabetes was added in this section.

 

A new section was added on post transplantation diabetes mellitus. Patients should be screened after organ transplantation for hyperglycemia. The preferred test to make a diagnosis of post transplantation DM is the oral glucose tolerance test.

 

SECTION 3. Comprehensive Medical Evaluation and Assessment of Comorbidities

 

The beneficial interactions between the patient and health care provider would determine the success of a medical evaluation. To optimize patient health outcomes and health-related quality of life, a patient-centered communication style is recommended. This style should use active listening and should elicit patient preferences and beliefs. Moreover, it should assess the literacy, numeracy, and potential barriers to care.

This section includes the components of the 2016 section “Foundations of Care and Comprehensive Medical Evaluation”.It emphasizes the importance of assessing comorbidities in the context of a patient-centered comprehensive medical evaluation.Due to the emergence of evidence suggesting a relationship between sleep quality and glycemic control, the Standard of Care now recommends the assessment of sleep pattern and duration as part of the comprehensive medical evaluation (table 3.1).

 

Diabetes comorbidities have now expanded to a list which includes autoimmune diseases, HIV, anxiety disorders, depression, disordered eating behavior, and serious mental illness.

 

SECTION 4. Lifestyle Management

                        

Previously this section was entitled “Foundations of Care and Comprehensive Medical Evaluation,” but now it is now focused on lifestyle management. Lifestyle management is a multifactorial aspect of diabetes care that includes self-management, education, nutrition therapy, physical activity, smoking cessation counseling, and psychosocial care.

 

Physical activity includes all movement that increases energy use and is an important part of the diabetes management plan. In this section, it has been recommended that all adults   especially those with type 2 diabetes, should avoid sedentary lifestyle. Prolonged sitting in type 2 adult diabetic patients is discouraged and a 30 minute-break is recommended for blood glucose benefits. Type 2 diabetics, should also have flexibility training and balance training 2-3 times/ week.

 

Another revision done in this section is the provision of information on situations that may warrant referral of a person with diabetes to a mental health provider for  evaluation and treatment (Table 4.2)

 

SECTION 5. Prevention or Delay of Type 2 Diabetes

 

It has been recommended that patients undergo informal or assessment tool screening from prediabetes and type 2 diabetes inorder to guide health care providers if diagnostic tests should be performed. The Diabetes Prevention Program (DPP) provides the strongest evidence for diabetes prevention. It has demonstrated that intensive lifestyle prevention could reduce the incidence of type 2 diabetes by 58% in the span of 3 years.

Pharmacologic agents such as metformin has demonstrated long term safety as drug therapy in disease prevention. However, new evidence has shown that long term use of metformin is associated with Vitamin B12 deficiency, hence there should be a periodic measurement of B12 levels.

 

SECTION 6. Glycemic Targets

 

Recommendations from the International Hypoglycemia Study Group on the classification of hypoglycemia is shown in Table 6.3. Clinically significant hypoglycemia is now defined as bloodglucose level of 54 mg/dL (3.0 mmol/L) while the glucose alert value is defined as<70 mg/dL (3.9 mmol/L).

 

SECTION 7. Obesity Management for the Treatment of Type 2 Diabetes

 

Obesity management has been proven to delay the progression from prediabetes to type 2 diabetes. It has also been proven to be beneficial in the treatment of type 2 diabetes. This section aims to provide evidence-based recommendations for the treatment of hyperglycemia in type 2 diabetes. An approach for treatment includes dietary, pharmacological, and surgical interventions for obesity management.

Bariatric surgery has a great role in the treatmentof type 2 diabetes. To reinforce its part, ADA now refers to it as metabolic surgery. The changes in this section include recommendations regarding metabolic surgery such as BMI thresholds for surgical candidacy, mental health assessment, and appropriate surgical venues. Metabolic surgery should be considered for adults with type 2 diabetes with body mass index(BMI) of 30.0–34.9 kg/m2 (27.5–32.4 kg/m2 in Asian Americans) if hyperglycemia is inadequately controlled despite optimal medical therapy by either oral or injectable medications (including insulin).

 

SECTION 8. Pharmacologic Approaches to Glycemic Treatment

 

From “Approaches to Glycemic Treatment” the title was changed to “Pharmacologic Approaches to Glycemic Treatment”. This was to emphasize that the section focuses on pharmacologic therapy alone. This section recommends that there should be a periodic measurement of B12 levels and supplementation if needed. This is to comply with the new evidence showing an association between B12 deficiency and long-term metformin use.

Results of two large clinical trials indicated that pharmacologic therapy of empagliflozin or liraglutide in patients with established cardiovascular disease, reduces the risk of mortality. Antihyperglycemic therapy in type 2 diabetes was updated to acknowledge the high cost of insulin. (Figure 8.1).

New tables were added showing the median costs of noninsulin agents and insulin inorder to address concerns about the affordability of antihyperglycemic agents.

 

SECTION 9. Cardiovascular Disease and Risk Management

The hypertension treatment recommendation for diabetes now suggests that, for patients without albuminuria, any of the four classes of blood pressure medications (ACE inhibitors, angiotensin receptor blockers, thiazide-like diuretics, or dihydropyridine calcium channel blockers) that have shown beneficial cardiovascular outcomes may be used.

In pregnant patients with diabetes and chronic hypertension, blood pressure targets of 120–160/80–105 mmHg are recommended in the interest of optimizing long-term maternal health and minimizing impaired fetal growth.

 

SECTION 10. Microvascular Complications and Foot Care

This section was added with a recommendation to focus on the importance of provider communication regarding the increased risk of retinopathy in women with preexisting type 1 or type 2 diabetes who are planning pregnancy or who are pregnant. Eye examinations should occur before pregnancy or in the first trimester in patients with preexisting type 1 or type 2 diabetes. Patients should be monitored everytrimester and for 1 year postpartum as indicated by the degree of retinopathy.

A recommendation on treatment of neuropathic pain was included in this section. Neuropathic pain can be severe and may impact the quality of life of a patient. There has been no strong evidence that glycemic control or lifestyle management can cure neuropathic pain which means that the only option is pharmaceutical intervention.  Pregabalin is the most studied drug and it has 30-50% improvement in pain. Duloxetine, on the other hand, has appeared to improve neuropathy related quality of life. Tapentadol, an opioid analgesic, is highly addictive and only offers modest pain reduction.

 

SECTION 12. Children and Adolescents

Seventy five percent of type 1 diabetes cases are diagnosed in individuals less than 18 years of age. In this section, recommendations were added to highlight the importance of assessment and referral of psychosocial issues of children and adolescents. Is is advised that upon diagnosis and during routine follow up care, an assessment should be done to address psychosocial issues and family stresses that could impact the patients’ health condition.

 A new recommendation was added to encourage preconception counseling starting at puberty for all girls with childbearing potential. Counseling could decrease the risk of malformations associated with unplanned pregnancies and poor metabolic control.

 

SECTION 13. Management of Disease in Pregnancy

                 Majority of diabetes in pregnancy is gestational diabetes mellitus (GDM) with the remainder primarily preexisting type 1 and type 2 diabetes.  Insulin is the preferred medication for treating diabetes in pregnancybecause it does not cross the placenta to a measurable extent. Metformin and glyburide can still be used but both cross the placenta to the fetus. All oral agents lack data in terms of safety for long term use.

                 To achieve glycemic control in both GDM and preexisting diabetes, it is recommended to monitor both fasting and postprandial blood glucose. However, preprandial self-monitoring of blood glucose was deemphasized in the management of diabetes in pregnancy.

Fasting and postprandial targets for pregnant women with GDM and preexisting diabetes were summarized as:

                                    ○ Fasting blood glucose of 95 mg/dL (5.3 mmol/L) and either

○ One-hour postprandial level of 140 mg/dL (7.8 mmol/L) or

○ Two-hour postprandial level of 120 mg/d (6.7 mmol/L)

 

SECTION 14. Diabetes Care in the Hospital

Hospitals have a duty to provide the shortest, safe hospital stay and promote an effective home that prevents acute complications and possible readmission. The changes made in this section was mainly to reorganize its structure for further clarity. 

A treatment recommendation was updated inorder to clarify that basal insulin or basal plus bolus correction insulin rather than sliding scale alone is the preferred treatment for noncritically ill patients and in patients put on nothing per orem (NPO). Sole use of sliding scale insulin treatment in the inpatient hospital setting is discouraged.Table 14. 1 shows the recommended insulin dosing for enteral and parenteral feedings.

 

Reference:

American Diabetes Association: Standards of Medical Care in Diabetes – 2017

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